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EARLY OUTCOME OF TRICUSPID REPAIR FOR FUNCTIONAL TRICUSPID
REGURGITATION ASSOCIATED WITH RHEUMATIC MITRAL VALVE DISEASE;
MODIFIED FLEXIBLE BAND ANNULOPLASTY VS. SUTURE ANNULOPLASTY
Abdelfattah I. and Omar A.
Ihab Abdelfattah, Lecturer of Cardiothoracic Surgery, Cairo University Alaa Omar, Lecturer of Cardiothoracic Surgery, Cairo University Objectives: we investigated early outcome of
follow-up by echocardiography, although the
flexible band as a piece of tube graft (PTFE)
difference was not statistically significant.
There was no need for reoperation or hospital
annuloplasty versus suture annuloplasty for
functional tricuspid regurge associated with
readmission for right-sided heart failure for
rheumatic mitral valve disease.
tricuspid regurgitation in both groups by the end
Methods: we prospectively reviewed patients
of first year postoperatively.
who underwent our technique of band tricuspid
annuloplasty (n=28) versus suture tricuspid
Conclusion: tricuspid band annuloplasty
annuloplasty (n=32) for functional tricuspid
using a piece of PTFE tube graft offered good
regurgitation concomitant with surgery for
outcome and tendency for improved durability
rheumatic valve disease with a mean follow up
than suture annuloplasty.
of 12 months.
Results: Thirty day mortality was zero in both
Key words: tricuspid regurgitation (TR) – band
annuloplasty – suture annuloplasty – DeVaga
groups. Tricuspid regurge grade was lower for
band group at discharge and after 12 months
repair-rigid ring - flexible ring
INTRODUCTION:
Although some reports suggest that tricuspid regurgitation can resolve after diseased mitral
valve has been replaced based on well known post-operative regression of pulmonary
hypertension (1,2), others suggest that ignoring a diseased tricuspid valve at the time of surgery
for left sided pathology can affect eventual outcome of the patient, and it may be associated
with an increase in morbidity and mortality (3,4,5).
Both ring and band annuloplasty have been performed for treating TR. Many types of rings and
bands rigid, semi-rigid or flexible were used with no clear evidence of superiority and durability
of each type (6).
In this study we investigated early postoperative outcome up to 1 year after tricuspid
annuloplasty for functional TR associated with rheumatic heart disease necessitating valve
surgery. We compared modified flexible band using sized PTFE tube graft annuloplasty, to
suture annuloplasty.
MATERIALS AND METHODS:
Patient population:
From March 2012 to May 2013, sixty patients underwent tricuspid valve repair together with
mitral and/or aortic valve surgery. We excluded patients with organic tricuspid valve disease.
Patients undergoing concomitant CABG, aortic aneurysm and root surgery, infective
endocarditis cases, low EF, together with redo cases were also excluded.
Tricuspid regurgitation was scored as follows:
Grade 1: mild regurge
Grade 2: moderate regurge.
Grade 3: moderate-to-severe regurge.
Grade 4: severe regurge.
Significant regurge was defined as regurgitation equal or more than grade 3.
End points:
The primary end points were:
• Postoperative hospital mortality
• The degree of tricuspid regurgitation (TR) upon discharge, and at 12 months follow up.
Secondary end points were:
• One year survival
• Hospital readmission for right-sided heart failure
• Need for reoperation for severe TR
Surgical Technique:
Conventional median sternotomy, standard cardiopulmonary bypass using bicaval cannulation.
Myocardial protection was achieved using antegrade intermittent cold cardioplegia. Mitral
valve replacement was performed with preservation of posterior leaflet in all patients. Tricuspid
valve annuloplasty was performed under cardiac arrest.
Saline infusion test was used to confirm adequate leaflet coaptation and competent
valve.Postoperative transthoracic echocardiography was performed upon discharge and 1 year
later.
1-Flexible Band:
Twenty-eight patients had repair of their TR using a piece of flexible polytetraflouroethylene
(PTFE) tube graft commonly used for aortic root replacement (figure 1). The band annuloplasty
was performed by a number of 2/0 Ethibond sutures starting from anteroseptal commissure to
end at posteroseptal commissure. Interrupted 2/0 braided sutures without pledgets were placed
circumferentially starting from anteroseptal commissure to posteroseptal commissure. Sutures
were then passed through the band. The band size for all cases was pre-determined length of 3
cm and 3 mm width. The width is roughly 2 rings of the tube graft. The 3 cm length is measured
Over a 10 ml syringe. 3 cm length is equal to the distance between the zero mark and the 6 ml
mark of the syringe (figure 2).
Fig. 1 flexible PTFE band
Sutures taken to plicate the annulus are
passed through the flexible PTFE band
Fig. 2 Sutures tied down and band fixed in-place
2- Suture Annuloplasty:
Standard DeVaga annuloplasty was performed in 18 patients, and segmental annuloplasty was
performed in 14 patients. 2/0 Ethibond sutures were used in all cases of suture annuloplasty
group.
Statistical Methods:
Data were statistically described in terms of mean ± standard deviation (± S.D), frequencies
(number of cases) and percentages when appropriate. Comparison of numerical variables
between the study groups was done using Student t test for independent samples. For comparing
categorical data, Chi square (χ2) test was performed. Exact test was used instead when the
expected frequency is less than 5. p-values less than 0.05 was considered statistically
significant. All statistical calculations were done using computer programs SPSS (Statistical
Package for the Social Science; SPSS Inc., Chicago, IL, USA) version 15 for Microsoft
Windows.
RESULTS:
Preoperative characteristics:
Preoperative demographics, NYHA class and echocardiography data showed no statistical
difference between the 2 modalities of annuloplasty.
Table 1 pre-operative patients characteristics
Suture group
(n=32)
42±12
Band group
(n=28)
39±14
p Value
14 (44%)
18 (56%)
13 (46%)
15 (54%)
0.6
TR Grade
PAP (mmHg)
CPB Time (Min)
3.25±0.76
67 ± 18
115± 37
3.46±0.63
62 ± 25
110± 45
0.8
0.7
0.3
Cross-Clamp Time (Min)
64 ± 27
75 ± 23
0.9
NYHA Functional Class
3.2± 0.6
3.4± 0.8
0.6
Age (yrs)
Gender
Male
Female
0.9
Endpoints:
Primary endpoints:
Hospital mortality:
• All patients in both groups were discharged from hospital in good condition with zero
hospital mortality.
Postoperative TR grade:
• There was significant improvement of TR grade postoperatively compared to
preoperative values in both groups (p=0.03 and 0.01 respectively). The mean
preoperative TR for the suture group was 3.25±0.76 and the mean preoperative TR for
the band group was 3.46±0.63 (table 1). At discharge the mean TR for the suture group
was 1.88 ± 0.73 and the mean TR grade for the band group was 1.79 ± 0.53 (tables 2,3).
Table 2 postoperativeTR grade for suture annuloplasty group
TR grade
1
Suture group (n=32)
At discharge (n=32)
9
12 month post op (n=30)
2
2
3
4
20
1
2
13
12
3
Mean ± SD
1.88 ± 0.73*
2.5±0.8
*p value 0.03 compared to preoperative value
Table 3 below highlights TR grades at time of discharge and at 1 year for the PTFE band group.
Table 3
Band group (n=28)
TR grade
At discharge (n=28)
1 yr post op (n=27)
1
8
4
2
18
15
3
2
6
4
0
2
Mean ± SD
1.79 ± 0.53*
2.22 ± 0.79
* p value 0.01 compared to preoperative value. The mean TR grade for the suture group at 12 months was 2.5 ± 0.8, and for the band group was
2.2 ± 0.79 with no statistical difference between the 2 groups (p = 0.9). Tables 2 and 3 capture the detailed hospital discharge and 12 months TR grades for both groups. Figure 3 compares the TR grade of the suture group to the band group at the three time points; preoperative, at discharge and at 12 months. The difference between the two groups was not statistically significant. 4 3.5 p = 0.1 3 2.5 suture group 2 band group 1.5 1 0.5 0 preopeartive at discharge 1 yr post op Figure 3 mean TR grade of the suture group and band group Secondary endpoints:
12 months survival:
• 2 patients in the suture group died . One patient died due to cerebral hemorrhage
complicating warfarin toxicity (5 weeks after discharge), and the other due to early
infective endocarditis over the prosthetic mitral valve (10 weeks after discharge). • In the band group one patient died almost 6 weeks after discharge. The patient was
admitted in the ER suffering from cardiac tamponade and an INR of 8. The patient then
rapidly went into cardiac arrest with failed attempts of resuscitation. Hospital readmission for right-sided heart failure:
Over the 12 months period of the study, none of the patients in both groups needed to be
readmitted to the hospital to control right-sided heart failure.
Re-operation:
After 1 year follow up and despite that some patients had tricuspid regurgitation grade 3 or 4
there was no need for reoperation and those patients were compensated on anti-failure
measures.
DISCUSSION
Functional TR occurs primarily due to annular dilatation and subsequently failure of leaflet
coaptation. Tricuspid annular dilatation occurs mainly in its anterior and posterior aspects,
which can result in significant functional TR as a result of leaflet mal-coaptation (4). Many
authors suggest that tricuspid annular dilatation is an ongoing pathology that will eventually
lead to severe TR. They advise early surgical correction regardless of the severity of TR. This is
due to the fact that uncorrected TR even without severe annular dilatation may worsen or persist
after mitral valve surgery, leading to progressive heart failure and poor survival (1,2,3).
However, the use of concomitant TV annuloplasty for mild/moderate functional TR remains a
controversial subject, because limited available data related to the long-term outcomes of
concomitant TV annuloplasty exist (8). Yilmaz, et al. concluded that TV annuloplasty is rarely
necessary for MV disease because TR progression after MV surgery is unlikely. They insisted
that progression of TR was clinically insignificant and did not lead to the risk of further surgery
(7). These patients often require substantial doses of diuretics to maintain Euvolemia (9).
Many studies report risk factors for recurrent TR following tricuspid annuloplasty. In one study
the authors reported that regardless of the types of annuloplasty, recurrence of TR early after the
procedure was associated with preoperative tethering of tricuspid valve leaflets, and
postoperative left ventricular dysfunction. Those two factors especially predict mid-term
outcome of tricuspid repair. Increased right ventricular pressure also results in worse TR during
mid- term follow-up. However, the authors did not report on the difference between the types of
annuloplasty as regards to better or worse outcome (6). The degree of tricuspid regurgitation
observed postoperatively in our study is comparable with results obtained from other studies.
In our study we fixed functional TR in patients with moderate-to- severe or severe TR. This is
consistent with most of the authors elsewhere. However, Murashita et al. recommends operating
on patients with even mild TR if a patient has atrial fibrillation or pulmonary hypertension (10)
TV annuloplasty is mostly applicable to patients with functional TR. However, the incidences
of residual and recurrent TR are reported to be high. McCarthy et al described 790 patients who
underwent TV suture annuloplasty for functional TR and found that the incidence of residual
TR was 15% one month after repair (11). Tang, et al. reported that there was a 30% TR
recurrence (among 702 patients) at a mean follow-up of 5.9 years after TV annuloplasty (12).
In the current study tricuspid regurge grade was lower in the band annuloplasty group, although
it didn’t reach statistical significance, for all grades of regurge severity. The reason may be
attributed to higher tensile strength of the PTFE graft compared to the suture material. One
other reason may be the pre-determined band length (3 cm) causing more plication of the
annulus as compared to the suture group. This under-sizing of the annulus may have contributed
to the tendency of less residual/recurrent TR postoperatively in the band group vs. the suture
group.
Although some patients suffered from late moderate TR in both groups, the clinical symptoms
were not significant. More than 50% of patients who had moderate TR were in NYHA
functional class I. the clinical condition was well controlled through medical treatment and non
of the patients in both groups required re-operation for their residual TR.
There were no differences in survival and freedom from major cardiac/cerebrovascular adverse
events between the two groups. However, freedom from moderate to severe TR was higher with
band annuloplasty than with suture annuloplasty, albeit the difference was statistically
insignificant.
Limitations:
1234-
Small number of patients.
Short period of follow up.
Single institution experience.
We have not examined the geometry of the tricuspid annulus following annuloplasty
with the two modalities by echocardiography. It would be interesting to see how the
flexible PTFE band behaves and whether the annulus keeps 3-dimensional geometry.
CONCLUSION:
Repair of functional TR by a piece of PTFE tube graft is a simple, safe and effective way to
manage moderate-to-severe and severe incompetence. There is tendency for lower incidence of
residual TR with this technique compared to suture annuloplasty up to one year postoperatively.
Longer follow up periods and larger number of patients is needed for better confirmation of
earlier promising results.
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